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Friday Mar 20, 2020

COVID-19: FP Searches for Supplies, Information and Lessons

As I write this, the novel coronavirus that sprang forth in China three months ago is spreading in my community. Last Thursday -- March 12 -- marked the first death in my state from the illness and an emergency declaration from the governor.(governor.kansas.gov) The spread isn't surprising after we saw the virus spread out of China and into other countries.

[Allison Edwards, M.D., in N-95 mask]

Here I am -- after much searching for N95 respirator masks -- ready for the night shift in an ER. In the midst of a pandemic, personal protective equipment is in short supply.

The United States had its first confirmed case on Jan. 21. Seeing what lay ahead, we started preparing our clinic in mid-February. I ordered an N95 fit-testing kit so we could figure out proper sizing for me and my staff. We also checked our supplies of gloves, surgical masks and hand sanitizer.

A week later, when the fit-testing kit arrived, it didn't actually come with N95 respirator masks, which should have been obvious in retrospect (and a pretty noob error to make). By the time we received the kit, figured out our mistake and placed an order for the N95 respirators, we hit a pretty big wall.

Our go-to medical supply vendors didn't carry N95 respirators. On Feb. 26 -- the same day the United States saw the first case of local transmission of COVID-19 -- we placed an order with a large, Fortune 10 medical supply company for N95s. We got a response that our items were on backorder. Out of concern about availability, we placed an order with a different national medical supplier for the same masks and got another message about backorders.

We have six staff to protect; I only requested 20 masks.

Five days later, we received word from the first medical supplier that our order was being canceled. The company was rationing its remaining supply to existing customers. Two days later, I checked my order with the second supplier and found that it had been canceled without explanation or notification.

I was furious. How was I supposed to protect my staff? How was I supposed to protect my patients?

The AAFP has taken steps to ensure the administration,(153 KB PDF) Congress(101 KB PDF) and federal agencies understand that family physicians need equipment to protect ourselves, our staff members and our patients. The Academy also is urging family physicians to contact members of Congress to call for rapid improvements in communication and coordination with frontline FPs. But what do we do while we wait for the government to act?

By this point in my search for supplies, our country had experienced its first deaths from COVID-19. Although the CDC continued to emphasize that travelers to countries with widespread, sustained transmission were most at risk -- and restricted testing to those who had a history of travel to those countries -- it was clear that the virus knew no state or political boundaries.

It was becoming obvious that even though my clinic sits in the middle of the country, far away from these initial domestic cases, we'd have to figure out how to protect our staff and patients. Soon.

Even with that realization, I felt completely alone and had no idea what to do or where to turn for help. The CDC recommended contacting county and state health departments, so I emailed urgent questions to both departments on March 1.

I never received a response from either.

The CDC continued to recommend using personal protective equipment, including gowns, gloves, eye protection and respirators, and triaging people into negative pressure rooms, but we only had gloves and eye protection. I kept hearing in the media and from politicians that there was, theoretically, the ability to test for COVID-19 -- but I had no idea how to access these tests.

At this point, I was beyond frustrated.

In a moment of desperation, I spent an entire morning calling hardware stores to see if they had any N95 respirators left in stock. The medical supply chain had failed; would the hardware supply chain come through?

After being put on hold and transferred between departments at a large, warehouse-style hardware chain, I started calling local hardware stores. A cheerful woman picked up at one of them. Losing all semblance of professionalism or even awareness that I'd bewilder this poor associate, I spilled forth my whole conundrum in a flood of words: I'm a family physician. I have a small clinic. I can't find masks to protect my staff and patients. I just need 20 respirators. I'm at my wits' end and the medical suppliers are all out of stock. Could she help? She put me on hold and quickly returned. She had found 12. And she'd hold them behind the register for me because, she said, "We have to take care of the doctors!"

I teared up and expressed my profuse thanks as I leaped out the door and jumped in my car to get them. I eventually found eight more at another hardware store.

Armed with the N95 respirators and what PPE we had on hand, I created a triage pathway that dictated what to do with which symptoms and how we planned to figure out who needed testing (and who didn't). In a major change of practice, anyone with respiratory symptoms was going to have their visit in their car in the parking lot. Our No. 1 goal was to prevent the spread of illness. I also sent an email to my entire patient panel, explaining the situation and what we would -- and wouldn't -- be able to do.

But as I walked into clinic the following Monday, March 9, I realized that I still didn't know what to do for those who screened positive and may warrant COVID-19 testing.

We got word through a state health department listserv that testing was now possible through the state and would be soon at commercial labs. I had also heard from a colleague that a national lab vendor had clearance to start testing, but the details were fuzzy. We didn't know the price, transport medium, storage specifications or ordering process.

Said in a different way: Both state and commercial vendors claimed to have testing capabilities, but we still didn't know quite how to go about accessing it.

On Wednesday, March 11, we finally received clear guidance from our lab vendor at almost the same time we received a triage algorithm from the state(www.kdheks.gov) that didn't mention supplies or price. Our commercial lab let us know that we could get supplies for 20 tests, and the price for each test would be $95. (However, they indicated most insurers likely would cover the cost of the testing). We also were informed that it would be a three- to four-day turnaround for results.

Part of my work involves traveling to rural ERs as a locum tenens physician. As I left my clinic on Thursday, March 12, for a week's worth of work in two different rural communities, I learned of the first death in my community:(www.kmbc.com) an elderly, bed-bound patient from a nursing home with no known travel history.

For the whole drive, my car radio buzzed with all of the most recent coronavirus news, fears and concerns.

I hadn't reached out in advance to the first hospital I was going to with questions about how they were planning for COVID-19, but I figured they would be better prepared (or would have at least had an easier time than I did in preparation). I'd tucked an N95 respirator in my bag before I left -- just in case.

I showed up on Friday -- the 13th -- at 6 a.m. to discover that the hospital had no N95 respirators. They did have a triage algorithm that invited anyone with respiratory symptoms to don a mask and enter the facility, but their risk factors for COVID-19 still listed travel to certain countries, despite the fact that the entire world had been elevated to a Level 2 travel advisory by the CDC.(wwwnc.cdc.gov) They weren't restricting visitors. Moreover, their algorithm hadn't yet been communicated to the registration desk.

I was stunned, but I immediately understood. Our clinic was small and agile and could make changes quickly (like when we transitioned exclusively to telehealth visits on March 16). This hospital, with its nine-person incident command team, had to make decisions by committee, and these committee decisions were being based on CDC guidance -- which itself was based on a committee that had to take the time to research and agree on a plan. They were already behind the eight-ball and severely underprepared.

I asked to meet with leadership and brought up my concerns. They acknowledged that the algorithm -- which had been released the day before -- needed to be updated.

At that point, I didn't want to wait for a committee to tell me how to protect staff and patients. I'm tired of being deferential to systems that break down. So, the managing nurse in charge of the ER, a hospital vice president, my charge nurse and I made a game plan.

Even though the Emergency Medical Treatment and Labor Act(www.cms.gov) allows for separate triage areas depending on clinical concerns, we were still going to follow the algorithm set out by the hospital. Those with respiratory symptoms deemed significant by triage staff would be placed in one of the two negative airflow rooms in the ER. Staff would wear ear-loop surgical masks or, if we were really concerned, we could don one of the 100-bed hospital's 15 purified air-powered respirators.

Oddly, we could not agree on the basic question of whether the virus was airborne or transmitted via droplet even though the CDC notes that the virus spreads via droplet.(www.cdc.gov) Half the algorithm was set up to address airborne pathogens; the other half was sufficient for droplet precautions.

It was a mess. I gave up. I wasn't in charge. And, after all, I had my N95 mask.

While we were arguing about the triage flow, news broke of the first local confirmed case of COVID-19(www.kshb.com) just down the road from the hospital in the city, where we transfer all of our acute patients.

Everything seemed to be changing so quickly.

Later that day, the Trump administration held a press conference declaring a national emergency while proposing several fixes. Among the proposals were two weeks of paid sick leave, up to three months of paid family and medical leave, unemployment benefits, federal funds for Medicare and free COVID-19 testing for those without insurance.

The testing bit caught my attention. Still thinking about my clinic and the logistics of testing, I searched for details but could not find anything helpful.

What a mess.

The question still remains: How am I supposed to protect my staff? How am I supposed to protect my patients?

I share all of this not to stoke fears but to express frustration as a front-line physician. We know what we need to do, but we can't do it.

We know we should be testing everyone to figure out who really has the disease and who doesn't. But there are a limited number of tests, and it still isn't clear who will be paying for the testing.

We know we need to keep health care workers healthy and that we should be protecting them with appropriate personal protective equipment. But there are limited numbers of respirators, gowns, gloves and negative pressure rooms.

We, the public, know we should be staying home. But how will we survive, economically and emotionally, if we do?

Last weekend, I spoke with a friend who asked if I was worried about COVID-19. I told her I am, but it's not the virus, specifically, that I'm worried about. It's the health care system's infrastructure that could break. It's our society's structure that will see the most harm. It's our economy that may not be able to withstand the pressure.

Even here in the ER, I am not yet in the thick of it, and I realize that any physician in Italy making life-determining decisions or a health care provider in the Pacific Northwest with dwindling supplies would dream of having any of the relatively simple problems I've laid out. But I guess that's my point: We will have these same problems soon.

I know I will become exposed to SARS-CoV-2 (the virus) and could potentially come down with COVID-19 (the illness). I know that given my age and health status, I'm at low risk of having serious complications or death. That's not my worry.

(My sister called this weekend, her voice breaking as she begged me not go to work. I explained, rationally, that I'd be OK. What I didn't say is that those of us in health care are a pathological breed: We work to help others, sometimes at our own peril.)(time.com)  

No, I'm not worried about myself. I am worried about protecting my staff and, more globally, creating systems to ensure that the health care system doesn't implode. I'm worried about preventing the spread to my patients.

More and more evidence is suggesting that carriers of SARS-CoV-2 may be asymptomatic.(www.ncbi.nlm.nih.gov) Particularly if the vast majority of us aren't able to self-quarantine (like, for example, the physician writing this who is expected to work and may become an asymptomatic carrier), we're going to see a lot of cases in the next few weeks. If we see a lot of cases, we're going to need a lot of hospital beds.

And a lot of masks.

And a lot of ventilators.

The U.S. health care system is made up of a largely uncoordinated network of businesses that distribute health care for profit. As such, the health care system is designed to run efficiently. There aren't extra gowns and respirators. There aren't extra ventilators. Extra would be inefficient, and inefficient businesses can't succeed. As we consider that 17.9% of our gross domestic product goes toward paying these health care businesses, has anyone stopped to ask if we are getting what we're paying for? Are we getting the safety and health we all expect (and deserve) at that price?

This crisis isn't one of medicine, necessarily. The root cause of this crisis is that the foundation of public health and primary care has been eroded to the point that we don't have the basic, nationally organized infrastructure to respond in a timely and adequate manner to a crisis.

This is a time when leadership matters. Large governmental, corporate and nonprofit actors have the opportunity to step up, push aside bureaucracy and give the most local actors -- those of us on the front lines -- a sense of agility to react and set up systems that work at a community level, but that have the science, financing and backing of a national force.

The last few days were a whirlwind. After the national emergency was declared, funding was allocated to expand testing capabilities, capacity and sites. The CDC doubled down on social distancing and the types of establishments and events that shouldn't be allowed. Additionally, President Donald Trump signed a relief package into law on March 18, a day after the administration proposed a $1 trillion economic stimulus package. Our leaders are slowly starting to wake up, but I still don't know how to protect my staff and my patients.

When we get to the other side of this crisis, let this serve as a case study of what not to do. Let us all take a step back and ask if the cost of simple public health interventions -- like a COVID-19 test for $95 -- should be borne by the individual or if this is something that we value enough to include as a collective good. Is access to basic care something that we value enough to provide to our citizens?

As we move forward, we will all suffer loss. We will suffer the loss of income. Of future earnings and retirement. Of autonomy. Of freedom of movement. Of the simple joys of gathering with those we love. We will, undoubtedly, suffer the loss of loved ones. We may suffer the loss of our own lives. We will certainly suffer the loss of our peace of mind.

For all the loss we will experience, I urge those in power: Let it not be in vain. Let us learn. Because there will be a next time. And I expect us, collectively, to do better.

Allison Edwards, M.D., founded and cares for patients at Kansas City Direct Primary Care,(www.kansascitydirectprimarycare.com) provides locums coverage at rural hospitals in Missouri, Kansas and Colorado with Docs Who Care; and is volunteer faculty at both the University of Colorado and the University of Kansas. You can follow her on Twitter @Dr_A_Edwards.(twitter.com)

Read other Fresh Perspectives posts by this blogger.

Posted at 10:34AM Mar 20, 2020 by Allison Edwards, M.D.

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